Policies & Guidelines
- Compliance
- Definitions
- Ambulatory Surgical Services
- Billing Policy
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Legal References
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- Ambulatory Surgical Services
- Billing Policy
- CFSS
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- Equipment and Supplies
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Member Eligibility
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Quality: HEDIS
- Policies & Procedures
Dental
Definitions
Crown: A restoration covering or replacing the major part of the whole portion of the tooth not covered by supporting tissues.
Dental Service: A diagnostic, preventive, or corrective procedure furnished by or under the supervision of a dentist.
Dental Surgery: Services performed by a dentist are defined as surgery when related to the jaw or any structure contiguous to the jaw. “Structures contiguous to the jaw” include structures of the facial area and below the eyes (e.g., mandible, teeth, gums, tongue, palate, salivary glands, or sinuses). This includes reduction of any fracture of the jaw or any facial bone, including dental splints or other applications used for this purpose.
Emergency Services: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. PrimeWest Health guidelines provide that the member must require immediate dental attention and is seen at the next available or the earliest opportunity.
Fixed Partial Denture (FPD) or Fixed Cast Metal Restoration or Fixed Bridge: A prosthetic replacement of one or more missing teeth that is cemented or attached to the abutment adjacent to the space filled by the prosthetic replacement and that cannot be removed by the patient.
Implant: Material inserted or grafted into tissue or bone; or a device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement.
Medical and Surgical Services: Medical and surgical services furnished by a doctor of dental medicine or a doctor of dental surgery (DDS) if the services:
- Are furnished by a physician, would be considered physician’s services; or
- Under the law of the state where they are furnished, may be furnished either by a physician, a doctor of dental medicine, or a DDS; and
- Are furnished by a doctor of dental medicine or a DDS who is authorized to furnish those services in the state in which he/she furnished the services.
Oral Hygiene Instruction: An organized education program by or under the supervision of a dentist to instruct a patient about the care of the patient’s teeth.
Rebase: The process of refitting a denture by replacing the base material.
Reline: The process of resurfacing the tissue side of the denture with a new base material.
Removable Prosthesis or Removable Dental Prosthesis: Includes dentures and removable partial dentures. Any dental device or appliance replacing one or more missing teeth, including associated structures, if required, that is designed to be removed and reinserted by the patient.
PW_03-19_130
Updated_03/13/2019
